Facts on Facial Fillers
Introduction to Injectable Fillers
The use of Injectable facial fillers is one of the fastest growing areas in the field of cosmetic surgery. Many advances in have been made in the last 5 years that have led to safer, more predictable and longer lasting fillers.
Historically, surgeons have injected substances into the face and lips for over a century. For the past 25 years, the choice of FDA approved fillers was very limited and basically was the use of bovine collagen (obtained from cows) products such as Zyplast and Zyderm. While these fillers were effective, they required allergy testing and a one month wait for injection after a negative allergy test. In addition, the did not produce lasting augmentation and the results were often gone at 3 months or less.
In December of 2003, the FDA approved Restylane for treating facial folds and wrinkles. Restylane represented a new type of filler and is made from hyaluronic acid which is a naturally occurring carbohydrate that is found in the skin and other tissues of all mammals. This substance is a clear gel with similar consistency as hair gel. Since it is not made from animal products, there is no need for allergy testing which is a huge advantage as the patient can come to an office and have same day filler injection. In addition, the hyaluronic acid fillers have a chemical process known as “cross linking” which prolongs their effect in the body, giving augmentation that can last 8-12 months. Medicis, the company that makes Restylane also has a more robust filler known as Perlane which was FDA approved in 5-07. This is a thicker filler that is used for smile lines (nasolabial folds) and other areas and provides a firmer support and lasts longer than Restylane.
Since the FDA approval of Restylane, Allergan Inc. (the makers of Botox) have had 2 injectable fillers approved by the FDA in 2006. Juvederm Ultra is a hyaluronic acid filler similar to Restylane and Juvederm Ultra Plus is a larger particle, more robust filler, similar to Perlane. The hyaluronic acid based fillers (Juvederm and Restylane) currently remain the most popular filler choices.
Hylaform, Hylform Plus are animal based hyaluronic acid fillers FDA approved in 2004, formerly marketed by Inamed (now Allergan) that have declined in popularity with the newer non-animal derived hyaluronic acid fillers. Captique (also marketed by Allergan) is an additional non-animal hyaluronic acid filler that was FDA approved in 2004.
There is a continued effort to develop longer lasting fillers. Although a permanent filler may sound like a perfect thing, if a patient has complications such as over fill or asymmetry, then permanent may not be a good thing! In experienced hands, the longer lasting fillers work well and their lasting effect is appreciated by both surgeons and patients.
There are numerous fillers that claim to last longer than the hyaluronic acid fillers. One of these FDA approved fillers is Radiesse. This filler is made from a substance that has similar properties to the organic matrix in bone or sea coral. These fillers have a consistency similar to tooth paste and due to their composition, can last up to 18 months. Radiesse is most often used in the nasolabial folds and for cheek augmentation, but may be used in the lips by some injectors. Since this is a thicker filler, it is generally used in deeper areas of the skin so there are not irregularities in the superficial skin.
Another new, longer lasting filler is Artefil. This filler consists of microscopic plastic beads that look like pearls under a microscope. The beads are mixed in a collagen carrier for injection. Since the beads are plastic, they will remain in place permanently and thus provide a lasting augmentation. One drawback to this filler is that since it contains collagen, it requires allergy testing one month before injection.
With the previously described fillers, they work by filling the lip or wrinkle with volume and are gradually digested by the body. Basically, when these fillers are injected, “what you see is what you get”. There exists another class of injectable fillers that work in a different manner than simple augmentation. Silicone and Sculptra work by an alternate method. These fillers are injected into the deeper skin and they cause the body to make new collagen. When these fillers are injected, they cause the collagen reaction that actually causes the area to grow over a 3-4 week period. This means that when Silicone of Sculptra are injected, there may be little noticeable result at first, but over the next month, the body will produce collagen in the injected areas and the augmentation will actually grow. With Silicone, very small micro droplets are injected into the lips or wrinkles and over the next month these tiny droplets of silicone will become surrounded with collagen and enhance the augmentation. Since the Silicone will “grow” it is injected in very small volumes on a monthly basis until the desired result is achieved. Silicone is considered a permanent filler as it stays in place and the body does not digest it.
Sculptra is substance known as L-Poly Lactic Acid which is similar to the material used to make a type of suture that is used to close lacerations. This material, similar to Silicone, will cause the body to make new collagen in the area where the filler is injected. Due to this, the reaction (like Silicone) is not immediate but increases over the next 3-4 weeks after injection. Sculptra is popular for injection into the nasolabial folds and for cheek augmentation. Some surgeons may also inject Sculptra in the lips and other regions of the face. Sculptra, like Silicone does not require allergy testing.
Since the science of fillers is so prolific, we will see new fillers introduced on a regular basis. In Europe, cosmetic surgeons have over 70 choices of various injectable filler products. Several very recent FDA approved fillers include Evidence, Elevess, and Prevelle.
Elvess is a hyaluronic acid filler that contains local anesthetic (0.3% lidocaine) and was FDA approved in 12-07. By combining a local anesthetic with the filler, the injection process is more comfortable for the patient, although most surgeons use local anesthetic injection routinely before filler administration. Prevelle Silk is another hyaluronic acid filler with local anesthesia marketed by Mentor and is representative of the process of adding lidocaine to the actual filler product.
Evolence is a filler that is made from porcine collagen (derived from pig tissue) and claims to last up to a year when injected into the nasolabial folds. Evolence has the consistency of a paste, does not require allergy testing and is yet another exciting example of the new generation of fillers.
Who is a Candidate for Injectable Fillers?
Facial fillers are administered over a wide age range. Younger patients may seek filler injection for lip plumping and fillers are used in the lips and other areas on aging patients. Men are also candidates for injectable fillers and are one of the fastest growing filler patient populations. Since filler injection is basically a simple and safe procedure most patients are candidates for injectable fillers if they want to plump their lips or wrinkles. Fillers should only be injected by appropriately trained personnel that can manage any potential complications.
Who is not a Candidate for Injectable Fillers?
Patients with significant allergies should check with their doctor before having any filler injected. Also patients taking aspirin or any medication that could affect blood clotting should notify their surgeon prior to injection to avoid hematoma, bleeding or severe bruising.
What is the Intended Result of Filler Injection?
Fillers are intended to plump lips and soften wrinkles. Different patients have different areas in need of improvement for their lips. Younger patients may only need some slight plumping to augment their already youthful lips while older patients may need plumping, outlining (restoration of the youthful border of the lips) and injection of lipstick lines.
For wrinkles and folds, fillers are intended to “soften” the wrinkle or fold, not to eliminate them. It is important that the patient has reasonable expectations prior to the treatment as not to be disappointed. If you consider the wrinkle a depression in the skin, the filler will plump up the depression to make it less severe, but will not make it completely disappear. Having realistic expectations is very important.
How Long Can I expect the Filler to Last?
Filler longevity is extremely variable and depends upon the type of filler used, the area it was placed and the metabolism of the individual patient. Fillers generally do not last as long in areas of extreme movement such as the lips as compared to less mobile areas like the cheekbones.
How is the filler administered?
Every surgeon has a different way of injection filler. Most surgeons will use a topical anesthetic cream and also administer local anesthetic injections (dental injections) prior to injecting fillers. Ice is also applied before and after injection. Injection generally only takes several minutes and some fillers cause immediate swelling so the patient may appear “over treated” at first. This swelling generally resolves in several hours. A follow up appointment several weeks after filler injection is a good idea so the surgeon can evaluate the result and touch up any areas in need.
What is the Recovery for Filler Injection?
For most patients, fillers can be injected in the lips or wrinkles and they can return to work the next day. Occasionally some patients will swell dramatically, especially in the lips, so for a first time patient; they may want to schedule the initial injection on a Friday. Occasionally patients will bruise from lip or wrinkle filling and this can usually be covered with makeup, but it is a good idea not to schedule filler injection right before an important social function in the event the patient experiences unusual bruising.
What are the Possible Complications of Injectable Filler Injection?
Like any procedure, filler injection can cause complications, but fortunately they are generally rare and minor. The most common post injection complications are swelling and bruising, both of which generally are short lived and self limiting. Over correction or under correction are also possible. For under correction, more filler can be added. In cases of over correction, sometimes the excess filler can be expressed out of the lip or wrinkle through a small needle puncture. Hyaluronidase is a medication that will dissolve the hyaluronic acid fillers and can be used to reduce areas of over treatment. Asymmetry is another possible complication where one side may be different from the other and again, requires filling of the deficient side.
In rare case allergic or foreign body reactions have been known to occur with fillers, but this is extremely rare. All of the above potential complications should be thoroughly discussed with your doctor before injecting fillers.
Injectable facial fillers have broadened the scope of minimally invasive cosmetic facial surgery and provided increased rejuvenative options for both doctors and patients. The represent an exciting and rapidly expanding part of anti-aging treatment and hold much promise for new fillers on the horizon. What used to require surgery can now, oftentimes be accomplished in several minutes with minimally invasive injectable facial fillers.
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Joe Niamtu, III DMD
Cosmetic Facial Surgery